[mmglobal]

Diane's case presents some very interesting issues. Last May, she was 49 years-old and had never had a hint of a back problem. In retrospect, she says that she was having some hip pain and leg pain that was probably from her back. But, being a nurse, working 12.5 hour shifts... sometimes 3 days in a row; she felt that she was probably getting arthritis.

Her problem started with some low back pain (LBP), but just a few weeks in, she was 100% leg pain, 0% LBP. She did conservative treatment for almost 3 months. She had a massive disc protrusion at L5-S1. (See her GPN story page for films and more detail.) Several of our favorite surgeons had told us that while some people recover spontaneously from disc herniations, with such a severe protrusion, if she's not going in the right direction at 2-3 months post onset; it was unlikely that she'd have a good recovery without surgery. So, sooner was better than later to maximize the chance of a good outcome. She went for endoscopic discectomy with Dr. Hoogland... July 30, 2007.

Dr. Hoogland's discectomy was successful in that it accomplished exactly what it was designed to do. He removed the disc protrusion, decompressing the offended nerves and almost completely resolved the left sided radicular symptoms associated with the left sided disc protrusion. Diane steadily improved for 2.5 months, then started having right sided symptoms. (If you are reading my other posts about Diane's case, much of this is redundant, but it's relevant for this discussion... sorry for the duplication.)

Keep in mind that since a short time after the onset of pain... she's almost 100% radicular pain. After she started to go south, we have asked ourselves if we should have gone straight to the ADR instead of doing the endoscopic discectomy? Being pragmatic, we will not kick ourselves... you make the best decisions possible with the information you have at the time. In the future, we may recommend a more critical eye be placed towards the quality of the disc before trying the less invasive surgery. In Diane's favor, she fit the exact profile of a perfect candidate.... recent onset... leg pain >> LBP. Working against here was the severity of the degeneration. Enough said... we chose an attempt at the less invasive option knowing that this was a possible outcome. We are VERY glad that Dr. Hoogland was able to do such an excellent job with the endoscopic procedure, limiting the amount of collateral damage, hopefully improving her chances in future surgeries if needed... and we needed that now! Following the onset of new right sided symptoms in late October... she started to get some increasing LBP... nothing horrible and she remained with leg pain >> LBP. In the very few weeks leading up to the surgery... she started to get LBP higher up. Coccyx pain is typical with L5-S1 problems, but she was having axial LBP higher than that.

When I came for my surgery 5.5 years ago, my big fear was that I'd return with 1 new disc, when I really felt that I was a 2-level. We did not think Diane was a 2-level, but I still had a great deal of anxiety about that... I knew that L4-5 was becoming dehydrated... it had a substantial bulge... but they type that could be completly asymptomatic as myelogram showed plenty of room in the canal area, and remember... she's mostly radicular pain... LBP is not a very big component of her problem. Discography showed more severe degeneration than we'd anticipated. Diane was surprised when she heard me exclaim, "yes", when Dr. B injected the contrast and I could see it flow all the way to the bulging PLL... even before he generated the pain response. I was glad that the discography was not going to yield ambiguous results. On further pressurization, it generated 7/10 concordant pain... and not just a little concordant... that is exactly her pain, when she feels the LBP. Either finding independantly would justify the 2 level... but both together made us both very relaxed... we knew that things were lining up and we have high confidence going into the surgery.

It's easy to lament the fact that we didn't do ADR last summer instead of the discectomy. Diane said, "if we went straight to ADR, we would have done a 1-level procedure. But, L4-5 is bad and we wouldn't have known it." She's right, and there is no telling if it would have been positive on discography. While it would seem that it must have already been degenerated... it was NOT generating any LBP back then... so it probably woudn't have shown up
as a pain generator. It is not unlikely that it also would have shown up as less degenerated as well.

The discussion about this prompted Dr. Bertagnoli to launch into a detailed discussion about how, especially at L5-S1, severe collapse is generally in a tilted forward direction (kyphosis), with the front collapsing more than the rear. This change in spinal balance and kinematics generates increased loads on the adjacent discs. If the discs are already degenerated, an overload will accelerate the degeneration. When discussion adjacent level degeneration, we are typically discussion levels adjacent to hardware. In this case, Dr. B calls it auto-adjacent level degeneration, or adjacent level disease associated with a configuration that has not been altered by hardware or other major surgeries.

There are many possibilities and we'll never know what might have been:

>> We could have had successful L5-S1 ADR months ago and that may have actually 'saved' L4-5 by restoring spinal balance before the overload configuration had a chance to further damage the disc.

>> We could have had successful L5-S1 ADR months ago and now or in the near future be facing more surgery... that would be Diane's third! I'm sure that there are many more options to discuss, but it's 2:30am after Diane's sugery and I'm exhausted... I'll be up for a while doing my post-op vigil, but will take a break after posting this.

One more important thing to note is that Diane's discography really kicked up her back pain. While the procedure was not very traumatic or painful beyond the short response when the disc was pressurized... it seemed to set her off substantially. The risks of discography are relatively low, but if a disc is very close to the edge, discography can push it over the edge. That is why I recommend that people only consider discography if they are prepared to act on the results if the news is bad. If you are not ready for surgery... don't do the disco.

I have recently had occasion to discuss this extensively with Dr. Regan. Remember that he was my surgeon in 2001 and he ordered my discography to rule-out L5-S1, hoping that I'd be in the Charite' clinical trail. Just a couple of weeks after my discogram, I was washing my hair in the shower and, BAM... my left foot went numb and I went from being 100% LBP to being 50/50 back and leg pain. I was surprised when Dr. Regan mentioned my case as an example of discography pushing a disc over the edge. I had been unwilling to draw the conclusion and was surprised that he had done so.

OK... another long winded mmglobal post. I regret not being able to write more in recent months... I have so much to share, but need to carve out the time. I'll try to get more done and with our extended stay in Germany... plus the great info we are getting during our ordeal... I expect to be able to produce a lot more.

All the best... please keep your fingers crossed for Diane.

Mark